Delivering free healthcare to rural Central Appalachia population: the

PROJECT REPORT

Delivering free healthcare to rural Central Appalachia population: the case of the Health Wagon T Gardner1, P Gavaza2, P Meade1, DM Adkins2 1

The Health Wagon, Clintwood, Virginia, USA Appalachian College of Pharmacy, Oakwood, Virginia, USA

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Submitted: 20 December 2011; Published: 20 March 2012 Gardner T, Gavaza P, Meade P, Adkins DM Delivering free healthcare to rural Central Appalachia population: the case of the Health Wagon Rural and Remote Health 12: 2035. (Online) 2012 Available: http://www.rrh.org.au

ABSTRACT

Central Appalachia residents present unique healthcare challenges. This vulnerable population faces poor health status and low access to health care. ‘The Health Wagon’ was established to innovatively enhance access to health care for the poor and marginalized rural population of Central Appalachia. This article describes the operations of the Health Wagon, a full mobile medical clinic, in delivering free health care to those in rural Southwest Virginia in Central Appalachia. The Health Wagon provides a wide range of comprehensive healthcare services, such as acute and chronic disease management, laboratory and diagnostic services, medication assistance, dental and eye care and specialty clinics for marginalized, poor and disenfranchised patients living in the mountains of that region. In 2009, a total of 157 clinics were provided and 2900 patients were seen (3165 patient encounters) in addition to 268 telemedicine specialty consultations at no cost to the patients. The work of the Health Wagon has broken down a financial barrier to healthcare access and offers unique and profound opportunities to improve health and expand health care in rural Central Appalachia. Key words: access barriers, Appalachia, free health care, USA.

© T Gardner, P Gavaza, P Meade, DM Adkins, 2012. A licence to publish this material has been given to James Cook University, http://www.rrh.org.au 1

Introduction Access to health care is a significant issue in American society1. Health outcomes are directly related to access to healthcare2,3; however, different US population groups have differential healthcare access, according to minority versus non-minority status, severity of illness/disease, race, ethnicity, socioeconomic status, and geographic (rural vs urban) location3. A large and growing section of society is unable to obtain quality healthcare services1,4. This is especially so in Southwest Virginia in Central Appalachia, where many people lack access to medical care due to a number of factors. This article describes the access to care issues of the population living in Southwest Virginia in Central Appalachia, and the innovative approach of the Health Wagon designed to address the problem of access to health care.

Background and health disparities in Southwest Virginia in Central Appalachia The Appalachian Region stretches from southern New York to northeastern Mississippi, a distance of more than 1609 km (1000 miles), covering 329 916 km2 (205 000 miles2) across 420 counties5. The region includes parts of Virginia, Kentucky, Tennessee, South Caroline, Alabama, Georgia, Maryland, Ohio, Pennsylvania, North Carolina, New York, Mississippi and all of West Virginia – a total of 13 states. The Appalachian Regional Commission divides the region into five sub-regions: Northern Appalachia, North Central Appalachia, Central Appalachia, South Central Appalachia, and Southern Appalachia, based on economic and demographic characteristics. This report concerns Southwest Virginia in Central Appalachia where the Health Wagon operates. The Southwest Virginia population is poorer than the rest of the nation and the poverty rate is higher than state (Virginia) average. In 2008, 24% of the Central Appalachian residents were poor5. Most people are unemployed, and unemployment rates are higher than state and national averages5. The Appalachian residents have

lower educational attainment than the rest of the state6, and relatively more people over the age of 25 years do not have a high school diploma compared with the state average. Southwest Virginia residents have poorer health outcomes compared with the rest of the state and nation5. Many people in Southwest Virginia smoke tobacco and are obese than the rest of the state7. Data from the Virginia Behavioral Risk Factor Surveillance System show that from 32.4% to 34.7% of the adults in Buchanan, Dickenson, and Wise counties are obese. Appalachian residents have higher rates of heart disease, diabetes, and cancer than the state and national averages5,8. The Centers for Disease Control found that cancer (lung, cervical and colorectal) death rates in rural Appalachia (176.3 per 100 000 population) and all of Appalachia (173.1 per 100 000 population) in the period 1994–1998 were much higher than the national average in the same time period9. Many Central Appalachia residents lack access to health care owing to factors such as lack of specialist services, long distances to travel in order to access services, limited public transportation, lack of health insurance, cost, and shortages of healthcare professionals10. The Central Appalachia region has a shortage of healthcare professionals and specialist services such as dentistry, mental health services and obstetrics services.

The Health Wagon The Health Wagon (www.thehealthwagon.org) was founded in 1980 to provide free health care to medically under-served people in the mountains of Southwest Virginia in Central Appalachia. The Health Wagon operates a mobile health clinic and a walk-in clinic from a fixed location to deliver care to residents of Buchanan, Dickenson and Wise counties. The Health Wagon provides comprehensive primary healthcare services that emphasize education and prevention free of charge to patients (although donations are encouraged and accepted). The Health Wagon also provides diabetic supplies and prescription medications through the state sponsored Pharmacy Connect Program at no cost to patients. The


Health Wagon coordinates Wise Remote Area Medical which is the largest free outreach of its kind in America. The work of the Health Wagon has been covered by several national and international media organizations such as AARP Magazine, Time Magazine Online, BBC, National Public Radio, Paris Match, Zuma Press, Associated Press, Reuters, and CNN. In addition, the Health Wagon and its executive director have been recognized by several awards: 2009 AANP Nurse Practitioner State Award for Excellence, 2008 Kid’s Central Community Service award, 2007 Virginia Governor’s Nonprofit Outstanding Nonprofit Award, 2004 Virginia Rural Health Association’s Best Practices Award, 2004 Virginia Governor’s community Service and Volunteerism Administrative Award.

Human and financial resources The work of the Health Wagon is possible due to the efforts of its board, staff, volunteers, organizational partners and funders. It is the recipient of Federal funding and receives financial support from a pharmaceutical company (Astra Zeneca Foundation) and private foundations and corporations. Staff and board of directors: The Health Wagon is directed by a 13 member board of directors. The Health Wagon is headed by an executive director who is a doctoral trained certified family nurse practitioner. The Health Wagon employs two full-time certified family nurse practitioners, four nurses, two office staff, a social worker, data systems coordinator, program developer and a part-time clerk.

Patients Most of the patients (61%) seen at the Health Wagon do not have health insurance and report that they cannot afford health care (Table 1). Some patients who have insurance also come to the Health Wagon because they cannot afford the copayment charged at other institutions (Table 1). The top nine diagnoses of the patients seen in 2009 were: 1. 2. 3. 4. 5. 6. 7. 8. 9.

hypertension diabetes major depressive disorder dyslipidemia (high cholesterol) obesity chronic obstructive pulmonary disease hypothyroidism gastro esophageal reflux disease acute illnesses (eg upper respiratory tract infections, ‘strep throat’).

In 2009, a total of 157 clinics were provided and 2900 patients were seen (3165 patient encounters) in addition to 268 telemedicine specialty consults. In 2009, there was a 20% increase in patient volume compared with 2008 (3165 patients received comprehensive healthcare services). The average age of patients in 2009 was 43 years and 16% of these were disabled (Table 2).

Volunteers: Volunteers include several community members (through the Experience Works Program), healthcare professionals (mostly nurses) and students (most are from University of Virginia at Charlotesville, Appalachian College of Pharmacy and East Tennessee State University on clinical rotation or practicum). Other volunteers help with mailing (newsletters, reports etc), filing, faxing, receptionist duties, and calling patients about specialty clinics. No recent data exist on volunteer hours but it is estimated that 2500 hours are donated by volunteers annually. Organizational partners: In providing health care, the Health Wagon collaborates with many partners, including the University of Virginia Health Systems; Dickenson Community Hospital (which conducts most of patients’ laboratory and diagnostic tests); Amerigroup; the Richmond Diocese of the Catholic Church; The American Breast Cancer Foundation; the United Breast Cancer Foundation; Appalachian College of Pharmacy (which conducts health education for patients on topics such as smoking and nutrition); East Tennessee State University; Mountain States Health System (provides specialist diabetology); and Lenowisco and Cumberland Health Districts. Other partners include Virginia Health Care Foundation, Virginia free clinic Association, Norton Community Hospital, Health Appalachia and University of Virginia Health System (Telemedicine).


Table 1: Reasons (%) given by patients for visiting the Health Wagon in 2009 Reason No insurance, cannot afford health care Have insurance, cannot afford co-payment Clinic convenience Other Need assistance with medications Care given by staff Another provider referred for medication/laboratory assistance No transportation

% 61 10 7 6 8 5 2 1

Table 2: The Health Wagon patients’ demographics, 2009 Demographic item Age